Examkin

Question

Difficulty: MediumBasic Care and Comfort

A nurse is admitting a client who has just returned to the clinical unit following a percutaneous liver biopsy. As part of the care plan to ensure optimal comfort and minimize post-procedure complications, which action is most appropriate for the nurse to take?

  1. Assist the client into a right side-lying position with a folded towel under the puncture site.Answer
  2. B
    Elevate the head of the bed to a high-Fowler's position to facilitate maximal lung expansion.
  3. C
    Delegate the initial post-procedure vital sign measurements to an unlicensed assistive personnel (UAP).
  4. D
    Apply soft wrist restraints immediately if the client exhibits mild restlessness from the procedure.

Answer

The nurse should assist the client into a right side-lying position with a folded towel placed under the puncture site.
Following a percutaneous liver biopsy, the client must be positioned on their right side (right lateral decubitus) for at least 2 hours. This positioning utilizes the body's weight to apply direct, external pressure to the liver capsule at the biopsy site, significantly reducing the risk of internal hemorrhage and providing physical support to the area for comfort.

Step-by-Step Solution

1
Identify the primary physiological risks associated with the procedure.
A percutaneous liver biopsy involves puncturing the highly vascular liver, making hemorrhage the most significant immediate post-procedure risk.
Understanding anatomical risks determines the necessary nursing interventions for safety and basic care.
2
Determine the optimal positioning to mitigate these risks and provide comfort.
Positioning the client on their right side applies external mechanical pressure directly to the liver capsule and biopsy site.
Direct pressure promotes hemostasis at the puncture site and stabilizes the area to improve overall client comfort.
3
Evaluate other potential actions for safety, scope of practice, and appropriateness.
Assessments cannot be delegated immediately post-procedure, restraints are not indicated for mild restlessness, and high-Fowler's position removes necessary pressure from the site.
Ensuring the chosen action is both within the RN's scope of practice and physiologically sound is required for safe care.

Key Concept

Post-Procedure Positioning and Hemostasis
Rate this question

Topics

Basic Care and Comfort

More questions from this topic